NCLEX PREP Leadership Management

The nurse has received her client assignment for the day. Which client should the nurse care for first? Rationale:Airway, breathing, and circulation take precedence, in that order of priority. The client with shortness of breath takes priority over the other clients. The clients in options 3 and 4 would be cared for next, followed by assessment of the client who was admitted for observation.Cognitive Ability: SynthesizingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic Words, ABCs—Airway, Breathing, CirculationPriority Concepts: Care Coordination, Safety 1.The 43-year-old client admitted for observation who has absence of bowel sounds 2.The 53-year-old client with heart failure who has gained 4 pounds (1.8 kg) since yesterday and is short of breath 3.The 49-year-old client who is scheduled for surgery within the next 2 hours and will undergo a hysterectomy 4.The 12-hour postoperative client who has undergone pneumonectomy and is completing a blood transfusion

2.The 53-year-old client with heart failure who has gained 4 pounds (1.8 kg) since yesterday and is short of breath

The nurse is preparing the client assignment. Which should be assigned to a licensed practical nurse (LPN)? Rationale:Oral medication administration is within the scope of practice for an LPN. Teaching is the responsibility of the registered nurse (RN). Assessments are also done by the RN. The LPN's scope of practice is restricted to data collection.Cognitive Ability: CreatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): Subject, Comparable or Alike OptionsPriority Concepts: Care Coordination, Leadership 1.A client who requires teaching about an insulin pump 2.Completing an admission assessment on a newly admitted client 3.Administration of a new oral medication to a client with Alzheimer's disease 4.An assessment of a client whose pulse oximetry reading is 85% and who is having difficulty breathing

3.Administration of a new oral medication to a client with Alzheimer's disease

The nurse is preparing to perform a general survey of a client who was admitted to the hospital a few hours ago. Which components of the general survey may be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1.Inspecting skin surfaces 2.Observing the client's behavior 3.Measuring the client's height and weight 4.Assessing the client's general appearance 5.Monitoring oral intake and urinary output

2.Observing the client's behavior 3.Measuring the client's height and weight 5.Monitoring oral intake and urinary output Rationale:The general survey is a review of the client's main health problems and includes assessment of vital signs, height and weight, general behavior, and appearance. The nurse can delegate some aspects, such as measuring height and weight and monitoring intake and output, to UAPs, but the nurse is responsible for performing the general survey, including assessment of general appearance, behavior, and skin. Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Planning Content Area: Leadership/Management: Delegating Strategy(ies): Subject Priority Concepts: Care Coordination, Safety

A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they should be performed. All options must be used. Give the client ½ cup (118 mL) of fruit juice to drink. Take the client's vital signs. Retest the blood glucose level. Check the client's blood glucose level. Give the client a small snack of carbohydrate and protein. Document the client's complaints, actions taken, and outcome.

1. Check the client's blood glucose level. 2. Give the client ½ cup (118 mL) of fruit juice to drink. 3. Take the client's vital signs. 4. Retest the blood glucose level. 5. Give the client a small snack of carbohydrate and protein. 6. Document the client's complaints, actions taken, and outcome. Rationale:The client is experiencing symptoms of mild hypoglycemia. If symptoms such as hunger, irritability, shakiness, or weakness occur, the nurse first will check the client's blood glucose level to verify that the client is experiencing hypoglycemia. Once this is verified, the nurse will give the client 10 to 15 g of carbohydrates, such as a ½ cup (118 mL) of fruit juice. The nurse will retest the blood glucose level after 15 minutes. While waiting the 15 minutes, the nurse will check the client's vital signs. The nurse will give the client another 10- to 15-g carbohydrate food item if the client's symptoms do not resolve. Otherwise, the nurse will provide a small snack of carbohydrates and protein if the client's next scheduled meal is more than 1 hour away from the time of the occurrence. After treatment and resolution of the hypoglycemic event, the nurse will document the occurrence, actions taken, and outcome. Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Leadership/Management: Prioritizing Strategy(ies): Subject Priority Concepts: Clinical Judgment, Glucose Regulation

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1.The acuity level of the clients 2.Specific requests from the staff 3.The clustering of the rooms on the unit 4.The number of anticipated client discharges 5.Client needs and workers' needs and abilities

1.The acuity level of the clients 4.The number of anticipated client discharges 5.Client needs and workers' needs and abilities Rationale:There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Planning Content Area: Leadership/Management: Delegating Strategy(ies): Maslow's Hierarchy of Needs Theory, Subject Priority Concepts: Clinical Judgment, Professionalism

The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which statement by the nurse manager reflects the manager's use of legitimate power? Rationale:Option 3 describes legitimate power. Legitimate power is based on a person's position within an organization or society. The organizational leadership has mandated performance outcomes, and management has the responsibility to see that the mandate is met. Option 1 demonstrates informational power. The manager is using data to drive compliance with the mandate. Option 2 reflects an example of coercive power. Coercive power is a "do this or else" type of approach. Option 4 reflects expert power. The manager is asking the staff nurses to comply with the mandate because the manager possesses expert knowledge and skill levels. In addition to coercive, informational, expert, and legitimate power, the manager has referent, reward, and personal power.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Communication and DocumentationContent Area: Leadership/Management: DelegatingStrategy(ies): SubjectPriority Concepts: Communication, Health Care Organizations 1."The health care system services a client population that presents particular challenges. The changes made will enhance client safety and reduce errors." 2."If you don't follow the new policy and procedure, I'll have no choice but to give you a notice about poor performance, which could lead to termination of your employment." 3."Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." 4."You're just going to have to trust me on this one. I was a member of the committee that wrote the policy and procedure, and there are good reasons why the specific nursing actions need to be done this new way."

2."If you don't follow the new policy and procedure, I'll have no choice but to give you a notice about poor performance, which could lead to termination of your employment."

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? Rationale:Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.Cognitive Ability: SynthesizingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process: AssessmentContent Area: Leadership/Management: DisastersStrategy(ies): ABCs—Airway, Breathing, Circulation, Maslow's Hierarchy of Needs Theory, Strategic WordsPriority Concepts: Care Coordination, Clinical Judgment 1.A pregnant woman who exclaims, "My baby is not moving." 2.A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3.A young child standing next to an adult family member who is screaming, "I want my mommy!" 4.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

2.A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!"

The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? Rationale:The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: ImplementationContent Area: Leadership/Management: PrioritizingStrategy(ies): Comparable or Alike Options, Strategic WordsPriority Concepts: Care Coordination, Clinical Judgment 1.Finish the bed bath and then administer the pain medication to the other client. 2.Ask the UAP to find out when the last pain medication was given to the client. 3.Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4.Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

2.Ask the UAP to find out when the last pain medication was given to the client.

The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all that apply. 1.Provide monetary relief. 2.Provide crisis counseling. 3.Identify and train personnel. 4.Issue presidential declarations. 5.Deploy National Guard troops. 6.Handle inquiries from families.

2.Provide crisis counseling. 3.Identify and train personnel. 6.Handle inquiries from families. Rationale:In general, the ARC provides support to individuals involved in a disaster, whereas FEMA deals with regional responses to disasters, such as issuing presidential declarations, providing monetary relief, and deploying National Guard troops. The ARC has been given authority by the federal government to identify and train personnel for a disaster and provide disaster relief, including crisis counseling, operating shelters, and handling inquiries from families. Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Planning Content Area: Leadership/Management: Disasters Strategy(ies): Subject Priority Concepts: Health Policy, Leadership

The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign 4 clients and has 1 RN, 1 licensed practical (vocational) nurse, and 2 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? Rationale:When delegating nursing assignments, the nurse must consider the skills and educational level of the nursing staff. The licensed practical (vocational) nurse is skilled in wound irrigation and dressing changes, so this client would be assigned to this staff member. Collecting 24-hour urine and helping with a bed bath and frequent ambulation can most appropriately be assigned to the UAPs. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the RN.Cognitive Ability: CreatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): Strategic WordsPriority Concepts: Care Coordination, Leadership 1.The client who requires a 24-hour urine collection 2.The client with an abdominal wound requiring frequent wound irrigations 3.The older client requiring assistance with a bed bath and frequent ambulation 4.The client on a mechanical ventilator requiring frequent assessment and suctioning

2.The client with an abdominal wound requiring frequent wound irrigations

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action? Rationale:In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity at the heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as possible.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and LearningContent Area: Leadership/Management: PrioritizingStrategy(ies): Comparable or Alike Options, Strategic WordsPriority Concepts: Clinical Judgment, Tissue Integrity 1.Immobilize the affected extremity. 2.Remove jewelry and constricting clothing from the victim. 3.Place the extremity in a position so that it is below the level of the heart. 4.Move the victim to a safe area away from the snake and encourage the victim to rest.

3.Place the extremity in a position so that it is below the level of the heart.

The nurse is delegating the morning hygienic care of a man to the unlicensed assistive personnel (UAP). In reviewing the assigned tasks, the nurse should instruct the UAP to use an electric razor for which client? 1.The client with severe pain related to osteoporosis 2.The client with hypokalemia related to diuretic therapy 3.The client with thrombocytopenia related to chemotherapy 4.The client with an elevated white blood cell count related to infection

3.The client with thrombocytopenia related to chemotherapy Rationale:The client with thrombocytopenia has a low platelet count. Using a straight razor increases the risk of abrasion and bleeding caused by ineffective clotting capability. The client with hypokalemia has a low potassium level. Shaving the client has no relationship to the client's potassium level. The client with severe pain is not affected by the different choices in shaving tools. Likewise, the client with an elevated white blood cell count will not be affected by the different choices in shaving tools.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: ImplementationContent Area: Leadership/Management: DelegatingStrategy(ies): SubjectPriority Concepts: Clotting, Safety

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. 1.The nurse who never had roseola 2.The nurse who never had mumps 3.The nurse who never had chickenpox 4.The nurse who never had German measles 5.The nurse who never received the varicella-zoster vaccine

3.The nurse who never had chickenpox 5.The nurse who never received the varicella-zoster vaccine Rationale:The nurses who have not had chickenpox or did not receive the varicella-zoster vaccine are susceptible to the herpes zoster virus and should not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella-zoster virus or who did not receive the varicella-zoster vaccine are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster. Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Planning Content Area: Leadership/Management: Delegating Strategy(ies): Subject Priority Concepts: Infection, Safety

The nurse is monitoring a client in labor who is receiving oxytocin and notes that the client is experiencing hypertonic uterine contractions. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. Rationale:If uterine hypertonicity occurs, the nurse would immediately intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the oxytocin infusion and increase the rate of the no additive solution, position the client in a side-lying position, and administer oxygen by face mask at 8 to 10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal examination to check for a prolapsed cord. The nurse would check maternal blood pressure for the presence of hypertension or hypotension. The nurse stays with the client and contacts the health care provider (HCP) as soon as possible (or asks another nurse to contact the HCP) and then implements the HCP's prescriptions, including the administration of medications to reduce uterine activity.Cognitive Ability: SynthesizingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process: ImplementationContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic Words, SubjectPriority Concepts: Reproduction, Safety Stop the oxytocin infusion. Reposition the client. Administer oxygen by face mask at 8 to 10 L/min. Perform a vaginal examination. Check the client's blood pressure. Administer medication as prescribed to reduce uterine activity.

1. Stop the oxytocin infusion. 2. Reposition the client. 3. Administer oxygen by face mask at 8 to 10 L/min. 4. Perform a vaginal examination. 5. Check the client's blood pressure. 6. Administer medication as prescribed to reduce uterine activity.

The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents of school-age children. Which items should the nurse plan to include in disaster preparedness? Select all that apply. 1.Flashlight 2.Supply of batteries 3.Battery-operated radio 4.Extra pair of eyeglasses 5.4-week supply of water 6.4-week supply of nonperishable food

1.Flashlight 2.Supply of batteries 3.Battery-operated radio 4.Extra pair of eyeglasses Rationale:Options 1, 2, 3, and 4 should be identified as items to have on hand as part of disaster preparedness. A 3-day supply of water is recommended (1 gallon per client per day). Similarly, a 3-day supply of nonperishable food is recommended. A 4-week supply of water and food is unnecessary and not recommended. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management: Disasters Strategy(ies): Subject Priority Concepts: Client Education, Safety

The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? Rationale:Assignment of tasks to the UAP needs to be made based on job description, level of clinical competence, and state law. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse. The client described in the correct option has needs that can be met by a UAP.Cognitive Ability: CreatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): SubjectPriority Concepts: Care Coordination, Leadership 1.A client requiring dressing changes 2.A client requiring frequent temperature measurements 3.A client on a bowel management program requiring rectal suppositories and a daily enema 4.A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

2.A client requiring frequent temperature measurements

A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. Verify the health care provider's (HCP's) prescription for the blood transfusion. Ask a licensed nurse to assist in confirming vital signs and blood compatibility and verifying client identity. Ensure that an informed consent has been signed. Obtain the unit of blood from the blood bank. Hang the bag of blood. Insert an 18- or 19-gauge intravenous catheter into the client.

1. Verify the health care provider's (HCP's) prescription for the blood transfusion. 2. Ensure that an informed consent has been signed. 3. Insert an 18- or 19-gauge intravenous catheter into the client. 4. Obtain the unit of blood from the blood bank. 5. Ask a licensed nurse to assist in confirming vital signs and blood compatibility and verifying client identity. 6. Hang the bag of blood. Rationale:The nurse would first verify the HCP's prescription for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions, and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank, once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Once the blood has been obtained, 2 registered nurses or 1 registered nurse and 1 licensed practical nurse (depending on agency policy) must together check the label on the blood product against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. The nurse should measure vital signs and assess lung sounds and then hang the transfusion.Cognitive Ability: SynthesizingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process: ImplementationContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic WordsPriority Concepts: Clinical Judgment, Safety

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1.Actual or life-threatening concerns 2.Completing care in a reasonable time frame 3.Time constraints related to the client's needs 4.Obtaining needed supplies to care for the client

3.Time constraints related to the client's needs Rationale:Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management: Prioritizing Strategy(ies): Strategic Words Priority Concepts: Care Coordination, Clinical Judgment

The nurse determines that which client has the highest priority needs? Rationale:An elevated and irregular pulse rate requires immediate evaluation. A rectal temperature of 99.8°F (37.7°C) is also normal. The blood pressure reading of 110/70 mm Hg does not present a concern unless the client is symptomatic. An oxygen saturation percentage of 95% is a normal oxygen saturation reading.Cognitive Ability: SynthesizingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process: AssessmentContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic Words, ABCs—Airway, Breathing, CirculationPriority Concepts: Care Coordination, Clinical Judgment 1.The client who has a rectal temperature of 99.8°F 2.The client who has a blood pressure of 110/70 mm Hg 3.The client who has an oxygen saturation percentage of 95% 4.The client who has an irregular apical pulse of 120 beats per minute

4.The client who has an irregular apical pulse of 120 beats per minute

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply. Rationale:UAPs can perform tasks that are noninvasive. Therefore, options 1, 2, 4, 5, and 6 are tasks that the UAP can perform. The client in option 3 must be cared for by the registered nurse.Cognitive Ability: CreatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: ImplementationContent Area: Leadership/Management: DelegatingStrategy(ies): SubjectPriority Concepts: Care Coordination, Safety 1.A client needing a bed bath 2.A client needing to ambulate 3.A client needing packed red blood cells 4.A client requiring assistance with feeding 5.A client needing to have vital signs checked 6.A client needing to use the bedside commode

1.A client needing a bed bath 2.A client needing to ambulate 4.A client requiring assistance with feeding 6.A client needing to use the bedside commode

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply. 1.A confused older client who requires feeding 2.A client who requires turning every 2 hours 3.A client admitted with dehydration who is on strict intake and output 4.A client on 3 L of oxygen by nasal cannula and a pulse oximetry reading of 89% 5.A client who experienced a 10-beat run of ventricular tachycardia and hypotension on the previous shift 6.A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day

1.A confused older client who requires feeding 2.A client who requires turning every 2 hours 4.A client on 3 L of oxygen by nasal cannula and a pulse oximetry reading of 89% 6.A client 4 days postoperative after exploratory laparotomy who requires ambulation in the hallway 4 times a day Rationale:Activities such as turning, ambulation, maintenance of intake and output, and feeding can be delegated to the UAP. Therefore, clients 1, 2, 3, and 6 can be assigned to the UAP. The clients in options 4 and 5 are or have demonstrated recent instability and should be assigned to the registered nurse for comprehensive assessment. Cognitive Ability: Creating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Planning Content Area: Leadership/Management: Delegating Strategy(ies): Subject Priority Concepts: Care Coordination, Safety

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? Rationale:When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by UAP. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.Cognitive Ability: CreatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): Strategic Words, SubjectPriority Concepts: Care Coordination, Clinical Judgment 1.A client who requires a bed bath 2.An older client requiring frequent ambulation 3.A client who requires hourly vital sign measurements 4.A client requiring abdominal wound irrigations and dressing changes every 3 hours

4.A client requiring abdominal wound irrigations and dressing changes every 3 hours

When planning care, which client should the nurse assess first? Rationale:The client with a chest tube for a pneumothorax should be assessed first, based on the airway compromise. This client could very well have problems with breathing. A client with total parenteral nutrition and lipids will need a site and rate check. The client who had a cholecystectomy 2 days earlier needs to have the incision checked, and the client on contact isolation for MRSA has to be assessed by the nurse, but these conditions are not life threatening, as an alteration in breathing could be.Cognitive Ability: SynthesizingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: AssessmentContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic Words, ABCs—Airway, Breathing, CirculationPriority Concepts: Care Coordination, Safety 1.The client with a chest tube for a pneumothorax 2.The client who had a cholecystectomy 2 days earlier 3.The client who is receiving total parenteral nutrition and lipids 4.The client who is on contact isolation for methicillin-resistant Staphylococcus aureus (MRSA)

4.The client who is on contact isolation for methicillin-resistant Staphylococcus aureus (MRSA)

The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action? 1.Set priorities for the client. 2.Assess the client's readiness to learn. 3.Find out whether anyone lives with the client. 4.Use only 1 teaching method to prevent confusion.

2.Assess the client's readiness to learn. Test-Taking Strategy:Note the strategic word, initial. Recall that the client's readiness to learn is the initial step in the teaching-learning process. Also, the steps of the nursing process can be used to answer correctly. The correct option addresses assessment.

The nurse has received her client assignment for the day. Which client should the nurse check first? Rationale:Priority clients are those who have a problem or potential problem with airway, breathing, or circulation. A client who has just returned from surgery could experience problems with all three. The client experiencing severe pain would be attended to next. Then the nurse would care for the client who is hearing voices in his head, followed by the client who is in 4-point leather restraints.Cognitive Ability: SynthesizingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: ImplementationContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic Words, ABCs—Airway, Breathing, CirculationPriority Concepts: Care Coordination, Safety 1.A client experiencing severe pain 2.A client who is hearing voices in his head 3.A client who has just returned from surgery 4.A client who is in 4-point leather restraints

3.A client who has just returned from surgery

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? Rationale:Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.Cognitive Ability: AnalyzingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: PrioritizingStrategy(ies): ABCs—Airway, Breathing, Circulation, Strategic WordsPriority Concepts: Care Coordination, Clinical Judgment 1.A postoperative client preparing for discharge with a new medication 2.A client requiring daily dressing changes of a recent surgical incision 3.A client scheduled for a chest x-ray after insertion of a nasogastric tube 4.A client with asthma who requested a breathing treatment during the previous shift

4.A client with asthma who requested a breathing treatment during the previous shift

The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? 1.A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic treatment 2.A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected 3.A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of a gastrostomy feeding tube the next day 4.A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head

4.A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head Rationale:The infant or child who is the most unstable should be assessed first. A 6-week-old infant with an altered level of consciousness suspected to have resulted from shaken baby syndrome is the most unstable client because the infant could be developing increased intracranial pressure (ICP) and require interventions for the complications associated with increased ICP. The 6-year-old child on day 10 of antibiotics for bacterial meningitis is a stable client. The 2-year-old child with cerebral palsy being admitted for surgical placement of a gastrostomy tube will need an admission assessment, but this child is stable. The 16-year-old with a possible shunt malfunction could become unstable, but because this child is older and ready for the CT scan, he or she is stable at this time.Cognitive Ability: SynthesizingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic WordsPriority Concepts: Clinical Judgment, Interpersonal Violence

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. Rationale:In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: ImplementationContent Area: Leadership/Management: PrioritizingStrategy(ies): SubjectPriority Concepts: Leadership, Professionalism 1.Open doors to client rooms. 2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. 5.Relocate ambulatory clients from the hallways back into their rooms.

2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed.

The nurse has received the client assignment for the day. Which client should the nurse care for first? Rationale:The client admitted with neutropenia should be cared for first. The white blood cells serve as the primary defense against infections by destroying bacteria in the blood. The client is complaining of painful urination; therefore, the nurse should suspect urinary tract infection and act promptly to contact the health care provider because clients with neutropenia are more susceptible to bacterial infections. The client who is tolerating the chemotherapy regimen and has a question is not a priority. It is not urgent that the nurse see the client with dryness and itching from radiation first. This is an expected effect from radiation therapy. The client who has a mastectomy is expected to have sensations of tightness and pulling.Cognitive Ability: SynthesizingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic WordsPriority Concepts: Care Coordination, Safety 1.The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question about nutrition 2.The client receiving external radiation who has complaints of dryness and itching skin at the treatment area 3.The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site 4.The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination

2.The client receiving external radiation who has complaints of dryness and itching skin at the treatment area

A home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9 a.m. All clients live within a 5-mile radius. In order of priority, how the nurse should plan the assignments for the day? Arrange the actions in the order that they should be performed. All options must be used. Rationale:The nurse would plan to visit the client with diabetes mellitus first and draw the fasting blood glucose level because this client needs to remain NPO (nothing by mouth) until the blood is drawn. This client also would be unable to take any medication, such as insulin, until the blood is drawn. The nurse would plan to see the client requiring twice-daily dressing changes next because the dressing changes should be spaced as far apart as possible. The nurse then would plan to see the client being visited by the home health aide and provide instructions and directions to the home health aide regarding care of the client. The nurse then would visit the client requiring supervision of the dressing change and would perform the admission assessment next because that may take more time than the other clients. The nurse then would return to the client requiring the second twice-daily dressing change; dressing changes should be spaced as far apart as possible.Cognitive Ability: SynthesizingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic Words, SubjectPriority Concepts: Care Coordination, Leadership A client with diabetes mellitus who needs a fasting blood glucose level drawn The first dressing change for a client requiring twice-daily dressing changes A client requiring supervision of a dressing change A client requiring an admission assessment to home health care The second dressing change for a client requiring twice-daily dressing changes A client being visited by the home health aide at 1030

1. A client with diabetes mellitus who needs a fasting blood glucose level drawn 2. The first dressing change for a client requiring twice-daily dressing changes 3. A client being visited by the home health aide at 1030 4. A client requiring supervision of a dressing change 5. A client requiring an admission assessment to home health care 6. The second dressing change for a client requiring twice-daily dressing changes

The nurse is rearranging the client assignments after several discharges and admissions occurred. Which tasks should be assigned to the unlicensed assistive personnel (UAP)? Select all that apply. Rationale:Medication administration and invasive procedures, such as urinary catheterization for specimen collection, cannot be done by the UAP; therefore, these options are incorrect. The remaining options identify activities that can be performed by the UAP.Cognitive Ability: CreatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): SubjectPriority Concepts: Care Coordination, Leadership 1.Cleaning a client's dentures 2.Ambulating a postoperative client 3.Taking 4:00 p.m. vital signs on clients 4.Giving medications left by the nurse for the client to take 5.Assisting a client with a urinary drainage catheter into a chair 6.Obtaining a catheterized urinalysis and taking it to the laboratory

1.Cleaning a client's dentures 2.Ambulating a postoperative client 3.Taking 4:00 p.m. vital signs on clients 5.Assisting a client with a urinary drainage catheter into a chair

A registered nurse is delegating activities to the nursing staff. Which activities are most appropriate for the unlicensed assistive personnel (UAP)? Select all that apply. Rationale:Work that is delegated to others must be done consistent with the individual's level of expertise and licensure or lack of licensure. Based on the options provided, the most appropriate activities for a UAP are noted in options 1, 2, and 3. These options do not include situations to indicate that these activities carry any risk. Because the client needs to eat lying flat, the client is at risk for aspiration. Care related to IV therapy needs to be done by a licensed nurse.Cognitive Ability: AnalyzingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): Strategic Words, Subject, ABCs—Airway, Breathing, CirculationPriority Concepts: Care Coordination, Leadership 1.Collecting a urine specimen from a client 2.Obtaining frequent oral temperatures on a client 3.Accompanying a client being discharged to his transportation to home 4.Assisting a postcardiac catheterization client who needs to lie flat to eat lunch 5.Monitoring the amounts of fluid remaining in intravenous (IV) solution bags for a client receiving IV fluids

1.Collecting a urine specimen from a client 2.Obtaining frequent oral temperatures on a client 3.Accompanying a client being discharged to his transportation to home 4.Assisting a postcardiac catheterization client who needs to lie flat to eat lunch

The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first? 1. A primigravida client in the active stage of labor 2.A multigravida client who was admitted for induction of labor 3.A client who is not contracting but has suspected premature rupture of the membranes 4.A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor

4. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor Rationale:Magnesium sulfate is a central nervous system depressant, and the client could experience adverse effects that include depressed respiratory rate (fewer than 12 breaths/minute), severe hypotension, and absent deep tendon reflexes. This client should be seen before the clients in all other options because their conditions are stable. Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Assessment Content Area: Leadership/Management: Prioritizing Strategy(ies): Strategic Words Priority Concepts: Care Coordination, Clinical Judgment

The registered nurse is creating the plan for client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? Rationale:The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client on bed rest who requires ROM exercises. The UAP is trained in this procedure. The client receiving chemotherapy and the client receiving a blood transfusion require assessment skills that only a licensed nurse can perform. The client with diabetes mellitus who is being discharged will require predischarge review of diabetic management instructions and coordination of necessary home care services.Cognitive Ability: CreatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): Strategic WordsPriority Concepts: Leadership, Safety 1.A client scheduled to receive a blood transfusion 2.A client with bladder cancer who will be receiving chemotherapy 3.A client newly diagnosed with diabetes mellitus scheduled for discharge 4.A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours

4.A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome? 1."Cushing's syndrome is caused by excessive amounts of cortisol." 2."Cushing's syndrome is caused by decreased amounts of aldosterone." 3."Cushing's syndrome is caused by excessive amounts of antidiuretic hormone." 4."Cushing's syndrome is caused by decreased amounts of parathyroid hormone."

1."Cushing's syndrome is caused by excessive amounts of cortisol. Rationale:Cushing's syndrome is a condition caused by excessive amounts of cortisol. Options 2, 3, and 4 are inaccurate descriptions of this disorder. Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Leadership/Management: Delegating Strategy(ies): Subject Priority Concepts: Clinical Judgment, Leadership

The nurse is developing a client care assignment for a group of unlicensed assistive personnel (UAPs). What is the nurse's first step in planning and assigning clients? 1.Determine what skills can be delegated. 2.Determine the years of experience of each UAP. 3.Determine how much supervision is required for each client assigned. 4.Determine how many clients the agency allows to be delegated to each UAP.

1.Determine what skills can be delegated. Rationale:Knowing what skills can be delegated is essential when nurses assign client care to other health care personnel. Nurses must be familiar with their state's Nurse Practice Act, institutional policies and procedures, and the institution's job description for UAPs. Information from these sources is necessary to define the level of competency of UAPs. Determining how many clients to delegate is not the first step, and in fact most agencies do not state a specific number of clients that may be assigned. Determining years of experience is also not a first step, although a UAP's experience could affect the type of client assigned. How much supervision will be required is also important but, again, not the first step the nurse takes when delegating client assignment to the UAPs. Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Planning Content Area: Leadership/Management: Delegating Strategy(ies): Strategic Words Priority Concepts: Care Coordination, Safety

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? Rationale:The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a UAP would be to care for a client on bed rest who requires assistance with ambulation every 4 hours. The UAP is trained in this procedure. The client receiving parenteral nutrition and the client scheduled for a cardiac catheterization require the assessment skills that a licensed nurse can perform. Teaching needs to be done by the licensed nurse. The UAP does not have the education to teach a client about medications.Cognitive Ability: CreatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): Strategic Words, SubjectPriority Concepts: Care Coordination, Safety 1.A client scheduled to receive parenteral nutrition 2.A client who requires assistance with ambulation every 4 hours 3.A client scheduled for discharge who needs teaching about medications 4.A client with bladder cancer who is scheduled for a cardiac catheterization

2.A client who requires assistance with ambulation every 4 hours

The registered nurse (RN) has provided instructions to a licensed practical nurse (LPN) regarding administering enemas to a client scheduled for a barium enema. The RN has instructed the LPN to administer enemas until they are clear. The LPN tells the RN that 3 enemas were administered and that the returns are still not clear. What most appropriate instruction should be given to the LPN? 1.Administer 1 more enema. 2.Stop administering the enemas. 3.Continue to administer enemas until the solution is clear. 4.Wait for 1 hour and then continue administering the enemas.

3.Continue to administer enemas until the solution is clear. Rationale:Client preparation for a barium enema may include the administration of enemas before the test. If administering enemas until clear is prescribed on the morning of the test, enemas should be administered no more than 3 times. The continuous administration of enemas may cause fluid and electrolyte disturbances and imbalances. Cognitive Ability: Applying Client Needs: Physiological IntegrityI ntegrated Process: Nursing Process: Implementation Content Area: Leadership/Management: Delegating Strategy(ies): Strategic Words, Subject Priority Concepts: Elimination, Fluid and Electrolyte Balance

The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child? Rationale:If epiglottitis is suspected, the priorities are to maintain a patent airway and obtain a chest radiograph to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate placement of a surgical airway. Epinephrine is not used in the treatment of epiglottitis.Cognitive Ability: ApplyingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process: ImplementationContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic WordsPriority Concepts: Clinical Judgment, Gas Exchange 1.Prepare the child for tracheotomy. 2.Prepare to administer epinephrine. 3.Prepare the child for a chest radiograph. 4.Assist the health care provider with intubation.

3.Prepare the child for a chest radiograph.

The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two unlicensed assistive personnel (UAP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client should the RN most appropriately assign to the LPN? Rationale:The RN is legally responsible for client assignments and must assign tasks according to the guidelines of Nurse Practice Acts and the job description of the employing agency. A client scheduled for a cardiac catheterization requires physiological needs and frequent nursing assessments; this is the most appropriate assignment for the LPN. The RN can work with the LPN and supervise care. The UAP has been trained to care for a client on bed rest and on urine collection, provide assistance with ambulation, and perform ROM exercises. The RN would provide instructions to the UAP regarding the tasks, but the tasks required for these clients are within the role description of a UAP.Cognitive Ability: CreatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): Strategic Words, SubjectPriority Concepts: Care Coordination, Leadership 1.A client requiring frequent ambulation 2.A client scheduled for a cardiac catheterization 3.A client requiring range-of-motion (ROM) exercises 4.A client with a 24-hour urine collection who is on strict bed rest

2.A client scheduled for a cardiac catheterization

The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client? Rationale:Priority care is focused on the client who has an ineffective airway. Although postoperative home care teaching is essential before discharge, there is no indication that the client is ready for discharge. The client with venous stasis has a circulatory issue related to immobility but no indication of an absence of arterial circulation. The potential for infection as a result of long-term smoking is a risk but not the most immediate concern. All 3 problems are important, but the client in the correct option has an airway concern, which supersedes the other clients' immediate needs.Cognitive Ability: AnalyzingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process: AssessmentContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic Words, ABCs—Airway, Breathing, CirculationPriority Concepts: Care Coordination, Leadership 1.The client who lacks knowledge regarding postoperative home care 2.The client with problems clearing the airway related to abdominal incision pain 3.The client with tissue perfusion alterations related to postoperative venous stasis 4.The client who is at risk for infection related to a history of smoking for 20 years

2.The client with problems clearing the airway related to abdominal incision pain

The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise? Rationale:Tertiary prevention involves reduction of the amount and degree of disability, injury, and damage after a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of a crisis. There is no known quaternary prevention level.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: ImplementationContent Area: Leadership/Management: DisastersStrategy(ies): Data in the QuestionPriority Concepts: Health Promotion, Safety 1.Primary level of prevention 2.Secondary level of prevention 3.Tertiary level of prevention 4.Quaternary level of prevention

3.Tertiary level of prevention

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply. Rationale:UAPs cannot be assigned to a client requiring care that is more than basic. UAPs do not have the education to safely care for clients requiring more than basic care. Assigning a UAP to these clients presents an unsafe situation. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. The client receiving a blood transfusion requires monitoring for possible adverse reactions; licensed personnel are necessary. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. Unlicensed personnel cannot be assigned to a client who needs immediate postoperative assessment. These clients need to be cared for by a registered nurse (RN).Cognitive Ability: CreatingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): SubjectPriority Concepts: Care Coordination, Safety 1.The client receiving a heparin infusion 2.The client receiving a blood transfusion 3.The client receiving continuous oxygen at 2 L/min 4.The client recovering from Guillain-Barré syndrome 5.The client who just returned from surgery for a hip repair 6.The client on isolation for methicillin-resistant Staphylococcus aureus

3.The client receiving continuous oxygen at 2 L/min 4.The client recovering from Guillain-Barré syndrome 6.The client on isolation for methicillin-resistant Staphylococcus aureus

The nurse has received her client assignment for the day. Which client should the nurse care for first? Rationale:In this situation, the client with the pain reported at 7 out of 10 should be cared for first. The pain will intensify and be harder to manage if treatment is delayed. Caring for the client in pain may delay administration of the preoperative antibiotic but does not jeopardize safe and effective care. Shortness of breath is expected in a client with emphysema after ambulation and therefore is not the priority. Serous drainage is expected from a surgical incision and does not indicate an emergency.Cognitive Ability: SynthesizingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic WordsPriority Concepts: Care Coordination, Safety 1.A client requiring a preoperative intravenous antibiotic 2.A client with emphysema who has shortness of breath after just ambulating 3.A client with serous drainage on an incisional spinal wound post laminectomy 4.A client with postoperative pain reported at 7 out of 10, with 10 being the worst

4.A client with postoperative pain reported at 7 out of 10, with 10 being the worst

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? Rationale:In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: PlanningContent Area: Leadership/Management: DelegatingStrategy(ies): SubjectPriority Concepts: Care Coordination, Collaboration 1.Each staff member is assigned a specific task for a group of clients. 2.A staff member is assigned to determine the client's needs at home and begin discharge planning. 3.A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an unlicensed assistive personnel (UAP). 4.An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients.

4.An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients.

The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first? 1.The 11-year-old with burns to 10% of both legs 2.The sobbing 10-year-old with an obvious fracture of the forearm 3.The unconscious 14-year-old whose breathing is shallow at 12 respirations per minute 4.The confused 12-year-old with bright red blood pulsing from an open fracture of the femur

4.The confused 12-year-old with bright red blood pulsing from an open fracture of the femur Rationale:Triage systems identify who should be treated first. Rankings are based on immediacy of needs, including immediate threats to life such as airway compromise or hemorrhagic shock. The 12-year-old who is demonstrating confusion is becoming hypoxic because of profound blood loss. The other victims are more stable and could wait. Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Implementation Content Area: Leadership/Management: Prioritizing Strategy(ies): Strategic Words Priority Concepts: Clinical Judgment, Safety

The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first? 1.Victim with an open fracture of the left lower extremity 2.Victim who is crying hysterically and complaining of pain in the right ankle 3.Victim who is unresponsive and not breathing and whose left pupil is fixed and dilated 4.Victim with an apparent chest wall defect and asymmetrical chest wall movement

4.Victim with an apparent chest wall defect and asymmetrical chest wall movement Rationale:The victim in option 4 will continue to have a decline in respiratory status and imminent threat to life unless immediate intervention is instituted. The victims in options 1 and 2 have conditions that can wait to be treated. The victim in option 3 is dead.Cognitive Ability: SynthesizingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process: ImplementationContent Area: Leadership/Management: PrioritizingStrategy(ies): Strategic WordsPriority Concepts: Clinical Judgment, Safety

The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? Rationale:The nurse should instruct the UAP to check safety devices and skin integrity every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Teaching and LearningContent Area: Leadership/Management: DelegatingStrategy(ies): SubjectPriority Concepts: Health Care Quality, Safety 1.Every 2 hours 2.Every 3 hours 3.Every 4 hours 4.Every 30 minutes

1.Every 2 hours

A client with diabetes mellitus is admitted to the hospital for eye surgery. Which task can be delegated to the unlicensed assistive personnel (UAP)? 1.Orient the client to the hospital surroundings. 2.Instruct the client on how to apply the eye drops. 3.Listen to the client express his frustration or loss. 4.Review hand washing and hygiene practices with the client.

1.Orient the client to the hospital surroundings. Rationale:Orienting the client to the hospital room and surroundings is within the scope of the UAP's responsibilities. Instructing on the use of eye drops, reviewing hand washing, and therapeutically listening to the client's emotions require formative evaluation to gauge client readiness. These activities are the responsibilities of the registered nurse. Teaching and assessments cannot be delegated to UAPs. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Implementation Content Area: Leadership/Management: Delegating Strategy(ies): Subject Priority Concepts: Leadership, Safety

The nurse is responsible for the care of a client who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an unlicensed assistive personnel (UAP)? 1.Determining if the client has consistently been medication compliant 2.Providing distraction for the client by engaging the client in a board game 3.Discussing the frequency and duration of the hallucinations with the client 4.Assisting the client in identifying any new stressors he or she may be experiencing

2.Providing distraction for the client by engaging the client in a board game Rationale:Although all of the options represent appropriate interventions, UAPs are permitted only to engage the client in a distraction such as a board game, and so it is an intervention that the nurse may delegate after sufficiently instructing the UAP. The other options, assessing medication compliance, the characteristics of the hallucinations, and stressors, are nursing responsibilities and may not be delegated to a UAP. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process: Planning Content Area: Leadership/Management: Delegating Strategy(ies): Strategic Words, Subject Priority Concepts: Care Coordination, Safety